CITY OF RIALTO CITY CLERK'S DATE STAMP
1 OF LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES 2023 AUG - 3 PM 1: 05
TO PERSON OR PROPERTY
RECEIVED
1. Claims for delh, nur to person, or personal propy mist be fild older than six 6) months afer the occurance (Gov. Code 59112) L ER K
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §9111.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING
Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
RICHARD AREN GOINGS
FULL NAME DATE OF BIRTH
RIALTO, CA. 92376-3611
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A 1 NA
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 08-02-23
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Descrbe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
BASELINE AT ACACIA AVE (UNCONED AREA.
3. HOW DID DAMAGE OR INJURY OCCUR?
14l35 BENING NOR ACACIA AVE HEN I RARIVED AT BASELINE,/ HAD TO TIAN B BICKED OFF WITH CONTES ATTER I GOT HOME; STUINS 45 MIn I NOTICES THE PASLAGER SIDE REE TRE, WAILOR BY DZO ENL TOTAL FLATE / CALLED AMA, RAILS TIRE (CONED AREAS INNON LOCKAn AREA; / Gor/te)
4. WERE POLICE AT THE SCENE? • YES #NO WERE PARAMEDICS AT THE SCENE? • YES• NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
SEE ABOVE.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $148.70 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $_
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $/48.90 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 148.20
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | 1 TELEPHONE: < 1
DATE: TIME: • AM • PM DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners. accident by "B-1" and the point of impact by "X"
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
/ SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
RICHARD ALLERA GOINES 08-03-23
TYPE OR PRINT NAME DATE
SELF
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 AMERICA'S TIRE 8/03/2023
8: 3 ЛМ
RICHARD GOLINGS
CITY OF RIALTO
RIALTO, CA 92376
909.875.6303 (H) 2023 AUG - 3 PM I: 05
2003 FORD
RANGER RECEIVED
XL Mileage Unknown CITY CLERK
Torque Specs: 100
CAL 40 CA# ARD271871
16065 SIERRA LAKES PKWY Invoice
FONTANA: CA 92336 1454946
909.770.5001 -
Salesperson 2
NICHOLAS E S
Estimaten Completion Time 09:29 AM
32562 - 1 225 170
RHZ PHA PHANTO ROT SLASH 11.00
- 87.00
COLT PATTERN: 5--114.3
32662
NAN
PHA PHANTOM i11.00 91.00
TIRE MILEAGE WARRANTY: 45000
INFLATION F.035 R:035
8001:
CERTIFICATES FOR
REFUND, REPLACEMENT 16.71 15.71
For tire certificate details, see
www.americastire.com/customer - service/certificates
80075 STATE REQUIRED
HAN TIRE FEE 1.75
98937 1.75
ADJUSTMENT/BAL & VAL LIFETIME
MRN .00
W/CERTS .90
225 /70 815100T SL SW
MAN
PHA PHANTOM A/P 11.00 81.00
TIRE MILEAGE WARRANTY: 45000
lelt frost and sight rear to sp now to sear
INFLATI 3/ F:005 R:035
16.71 16.73
For tire certilicate details, see
www.americastire.com/customer-service/cerlificates
STATE REQUIRED
1.75 1,75
1 MASTE TIRE
DISPOSAL FEE 2.50 2.50
: INSTALLATION &
LIFE OF TIRE MAINTENANCE 22.00 22.00
Tire recommends that the new tires will be placec Whea replacing less than four tires, America's un the rear of the vehicle
The tire andlor wheel you have chosen is differen
Sone a a page le bating or stability
gharacteristics
her information is available from vo
perica's Tire salespers
Sub Total: 142.42
Sales Tax: 6 40
Sales Total: 148.90
Tendered: 14:1.90
(MSC)
Tendered Today: 148.90
Tendered Total: 141.90
tease register your new tires
OR go online le suze to mail in the tire registration car www.americastire.com/tire - registration
CITY OF RIALTO
2023 AUG - 3 PM |: 06
RECEIVED
ACACIA AVE. 0557889755
Rehan Ou BASELINTE
EUCALYATUS AVE.